RN exams clinical judgment practice questions, set 23
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 23
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Five clinical judgment questions with answers
Cover the key. Write the first action. Then open the rationale and name why the other choices fail.
Question 1
An adult oncology patient has a diagnosis of bladder cancer with metastasis and the patient has asked the nurse about the possibility of hospice care. Which principle is central to a hospice setting?
A. The patient and family should be viewed as a single unit of care.
B. Persistent symptoms of terminal illness should not be treated.
C. Each member of the interdisciplinary team should develop an individual plan of care.
D. Terminally ill patients should die in the hospital whenever possible.
Show answer and rationale
Correct answer: A — The patient and family should be viewed as a single unit of care.
The correct answer is A: The patient and family should be viewed as a single unit of care. In hospice care, the focus is on providing holistic care not only to the patient but also to their family members. This approach recognizes that the patient's well-being is interconnected with that of their loved ones. By viewing the patient and family as a single unit of care, hospice providers can address not just the physical symptoms but also the emotional, social, and spiritual needs of both the patient and their family. This principle emphasizes the importance of supporting the patient and their family through the end-of-life journey.
Summary:
- Choice B is incorrect as hospice care aims to manage symptoms effectively to improve quality of life.
- Choice C is incorrect as hospice care typically involves a collaborative interdisciplinary team working towards common goals.
- Choice D is incorrect as hospice care often prioritizes providing end-of-life care in a comfortable setting preferred by the patient.
Question 2
A client with disseminated intravascular coagulation (DIC) has a nursing diagnosis of Impaired Gas Exchange. Which action is appropriate when providing care based on this nursing diagnosis?
A. Place the client in low-Fowler position to improve gas exchange
B. Monitor the client's oxygen saturation intermittently
C. Encourage frequent amulation
D. Use continuous endotracheal suctioning instead of coughing and deep breathing
Show answer and rationale
Correct answer: B — Monitor the client's oxygen saturation intermittently
Monitoring the client's oxygen saturation intermittently is the most appropriate action when providing care for a client with disseminated intravascular coagulation (DIC) who has a nursing diagnosis of Impaired Gas Exchange. DIC can lead to a variety of complications, including inadequate oxygenation of tissues due to abnormal clotting and bleeding. By monitoring the client's oxygen saturation levels, the healthcare team can assess the effectiveness of gas exchange and adjust interventions as needed to optimize oxygenation. This action helps in early detection of worsening gas exchange and guides appropriate interventions to address any respiratory issues promptly. Placing the client in a low-Fowler position may not be suitable for all patients with DIC, encouraging frequent ambulation could be risky due to the increased bleeding tendency, and using continuous endotracheal suctioning is not recommended as it can lead to aggravation of respiratory issues and increase the risk of further complications.
Question 3
A patient with a brain tumor has begun to exhibit signs of cachexia. What subsequent assessment should the nurse prioritize?
A. Assessment of peripheral nervous function
B. Assessment of cranial nerve function
C. Assessment of nutritional status
D. Assessment of respiratory status
Show answer and rationale
Correct answer: C — Assessment of nutritional status
The correct answer is C: Assessment of nutritional status. Cachexia is a complex metabolic syndrome characterized by weight loss, muscle wasting, and weakness commonly seen in cancer patients. Assessing the patient's nutritional status is crucial to address the underlying causes of cachexia and to develop an appropriate management plan. This assessment includes evaluating dietary intake, weight changes, body composition, and nutritional deficiencies.
Choice A: Assessment of peripheral nervous function is not the priority in this case as cachexia is primarily related to metabolic and nutritional issues rather than peripheral nervous system dysfunction.
Choice B: Assessment of cranial nerve function is also not the priority since cachexia is not directly associated with cranial nerve dysfunction.
Choice D: Assessment of respiratory status may be important in general patient care, but in this case, addressing the underlying nutritional issues that are contributing to cachexia should be the priority.
Question 4
Which of the following most accurately describes the participation of prisoners in clinical trials and research?
A. There is no need for informed consent.
B. No monetary compensation may occur.
C. Prisoners are not permitted to participate as research subjects.
D. Their rights are identical to those of a nonprisoner.
Show answer and rationale
Correct answer: D — Their rights are identical to those of a nonprisoner.
Prisoners have the right to participate in clinical research trials. They are also entitled to monetary compensation for their participation. Participation cannot be used as a criterion for shortening their prison sentence. Essentially, prisoners have all the same rights in terms of their participation in clinical research as nonprisoners. This also includes the right to refuse participation. It is not unethical for them to participate. The ethical difficulties begin when the power of choice and informed consent are removed from the prisoner. Incarceration does not reduce the prisoner to the subhuman, animal-like status of unfair treatment or not having the right to refuse participation. Clinical trials that occur in a prison must undergo the same review process by an institutional review board (IRB) as those occurring outside the prison. You cannot force someone into research just because he is a prisoner. You cannot coerce them into participating by suggesting it will shorten the prison sentence.
Question 5
Patients with heart failure have extended lengths of stay and are often readmitted shortly after they have been discharged. To improve quality of care, a type of "road map" that included all elements of care for this disease and that standardized treatment by guiding daily care was implemented. This road map is referred to as a(n):
A. benchmark.
B. critical pathway.
C. algorithm.
D. case management.
Show answer and rationale
Correct answer: B — critical pathway.
The correct answer is B: critical pathway. Critical pathways are structured, multidisciplinary care plans that detail essential steps in the care of patients with specific conditions, such as heart failure. They standardize treatment by outlining the sequence and timing of interventions, tests, and medications, helping to improve efficiency and quality of care. Critical pathways guide daily care by providing a roadmap for healthcare providers to follow, ensuring that patients receive appropriate and timely interventions.
Explanation of other choices:
A: Benchmark - Benchmarks are standards or reference points used for comparison, not a structured care plan like a critical pathway.
C: Algorithm - Algorithms are step-by-step procedures for solving problems, not necessarily a comprehensive care plan like a critical pathway.
D: Case management - Case management involves coordinating care and services for individual patients, not a standardized care plan for a specific disease like a critical pathway.
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Question 6
Mr. L (tracheostomy and partial laryngectomy) has been receiving 10 mg of IV morphine for pain. The HCP tells the nurse that Mr. L will be switched to oral (liquid) hydromorphone 5 mg. When the nurse checks an equianalgesic dose table, she sees that 10 mg of morphine equals 5 mg of hydromorphone. What should the nurse do?
A. Call the pharmacy to double check that the equianalgesic dose is actually 7.5 mg.
B. Recognize that variable cross-tolerance necessitates upward titration for safety. c.
Correct answer:
Step 1: Understand that equianalgesic doses are based on average conversion ratios.
Step 2: Recognize that individual patient variations can affect opioid conversion accuracy.
Step 3: Understand that cross-tolerance can impact the efficacy of equianalgesic conversions.
Step 4: Acknowledge that upward titration may be necessary to ensure adequate pain control.
Step 5: Realize that starting with a lower dose of hydromorphone may not provide adequate pain relief due to potential cross-tolerance.
Therefore, the correct answer is B, as it emphasizes the importance of considering individual patient factors and the potential need for upward titration to ensure safety and efficacy in pain management.
Summary:
- Option A is incorrect because it focuses on verifying the equianalgesic dose rather than considering individual patient factors.
- Option C is irrelevant as it does not address the need for potential dose adjustment.
- Option D is incomplete and does not provide any guidance on managing the opioid
Following the death of a child, one of the parents begins to falsely accuse other members of the family of blaming the child's death on the parent. This leads to family members avoiding the mentioned parent for fear of the false accusation. The parent takes this as proof that the family truly believes the accusation. This sets up a destructive cycle of family dysfunction. Which nursing diagnosis is most appropriate for this family?
A. Impaired family processes related to impaired adjustment
B. Impaired adjustment related to loneliness
C. Loneliness related to fear
D. Dysfunctional grieving related to loss of relationships
Correct answer:
The correct answer is D: Dysfunctional grieving related to loss of relationships. This nursing diagnosis is most appropriate because the parent's behavior following the child's death is indicative of dysfunctional grieving, as they are falsely accusing family members and experiencing a breakdown in relationships. This behavior is a maladaptive way of coping with the loss, leading to further dysfunction within the family.
A: Impaired family processes related to impaired adjustment does not fully capture the specific issue of dysfunctional grieving and loss of relationships.
B: Impaired adjustment related to loneliness focuses more on the individual's emotional state rather than the family dynamics and dysfunction.
C: Loneliness related to fear does not address the core issue of dysfunctional grieving and the breakdown in family relationships.
In summary, the parent's behavior and the resulting family dysfunction point towards dysfunctional grieving as the primary nursing diagnosis in this case.
Which one of the following statements concerning massive hemothorax is true?
A. "It is usually caused by blunt thoracic trauma"
B. It is commonly confused with pneumothorax
C. The diagnosis should be confirmed by upright, plain chest x-ray prior to treatment
D. The condition should be suspected in situations with shock and unilateral absent breath sounds
Correct answer:
Rationale for Correct Answer (D):
1. Massive hemothorax is characterized by the accumulation of blood in the pleural cavity.
2. In situations with shock and unilateral absent breath sounds, there is a high suspicion for massive hemothorax due to significant blood loss and lung collapse.
3. Prompt recognition and treatment are crucial to prevent further complications and stabilize the patient.
4. Immediate interventions such as thoracostomy tube placement may be necessary to evacuate the blood and reexpand the lung.
5. Therefore, choice D is the correct answer as it highlights key clinical features and emphasizes the importance of early diagnosis and management.
Summary of Incorrect Choices:
A: Massive hemothorax can also be caused by penetrating trauma, not just blunt trauma.
B: Pneumothorax involves air accumulation in the pleural cavity, which is different from blood accumulation in hemothorax.
C: Delaying treatment for an upright chest x-ray may compromise the patient's condition as
Which of the following is an expected normal finding in the diagnostic positions test?
A. Convergence of vision in both eyes
B. Parallel movement of both eyes
C. Nystagmus in extreme superior gaze
D. A slight amount of lid lag when moving the eyes from a superior position to an inferior position
Correct answer:
The correct answer is D: A slight amount of lid lag when moving the eyes from a superior position to an inferior position. In the diagnostic positions test, when the eyes move from an extreme superior position to an inferior position, a slight amount of lid lag is expected due to the normal anatomical structure and mechanics of the eye muscles and eyelids. This lag is a normal finding and not indicative of any underlying pathology.
Rationale:
A: Convergence of vision in both eyes is not a normal finding in the diagnostic positions test as convergence refers to the inward movement of both eyes towards each other to maintain single binocular vision.
B: Parallel movement of both eyes is not a specific finding in the diagnostic positions test. The test is designed to assess the movement of the eyes in different directions.
C: Nystagmus in extreme superior gaze is not a normal finding and indicates an abnormality in eye movement coordination, not an expected finding in the diagnostic positions test.
Devastated by a divorce from an abusive husband, a wife completes grief counseling. Which statement by the wife would indicate to a nurse that the client is in the acceptance stage of grief?
A. If only we could have tried again, things might have worked out.Â
B. I am so mad that the children and I had to put up with him as long as we did.Â
C. Yes, it was a difficult relationship, but I think I have learned from the experience.Â
D. I have a difficult time getting out of bed most days.Â
Correct answer:
The correct answer is C: "Yes, it was a difficult relationship, but I think I have learned from the experience." This statement indicates acceptance because the wife acknowledges the difficulty of the relationship but also expresses personal growth and learning from it. Acceptance stage involves coming to terms with the reality of the situation and finding meaning or lessons in the experience.
A: "If only we could have tried again, things might have worked out." - This statement suggests bargaining, which is a stage before acceptance where the individual is trying to negotiate or change the outcome.
B: "I am so mad that the children and I had to put up with him as long as we did." - This statement reflects anger, another stage of grief where the individual may feel resentful or frustrated about the situation.
D: "I have a difficult time getting out of bed most days." - This statement indicates symptoms of depression or denial, which are common in earlier stages of grief, not acceptance.
The nurse is teaching a student nurse about some of the differences between a term and preterm infant. Which statement is most accurate?
A. Infants born at 32 weeks gestational age have sufficient alveolar stability to maintain adequate lung expansion.
B. Surfactant may need to be given to the infant born less than 34 to 36 weeks of age to assist with alveolar stability.
C. Women with gestational diabetes have larger babies; therefore, there are fewer issues with lung maturity when born preterm.
D. Mothers carrying multiples fetuses will increase the surfactant production naturally in utero.
Correct answer:
The correct answer is B because infants born before 34 to 36 weeks gestational age may not have fully developed surfactant production, which is crucial for alveolar stability and lung expansion. Surfactant reduces surface tension in the alveoli, preventing their collapse. Without sufficient surfactant, preterm infants are at risk of respiratory distress syndrome.
Choice A is incorrect because infants born at 32 weeks may still have underdeveloped alveoli and insufficient surfactant production, leading to potential lung expansion issues.
Choice C is incorrect because the presence of gestational diabetes does not guarantee sufficient lung maturity in preterm infants. Lung maturity is more closely related to gestational age and surfactant production.
Choice D is incorrect because while carrying multiple fetuses can slightly increase surfactant production, it may not be sufficient for preterm infants born before 34 to 36 weeks, necessitating the need for exogenous surfactant administration.
2 Which of the following is the best way for a nursing assistant to keep residents' health information confidential?
A. Discuss a resident's information away from the facility so that other residents cannot hear it
B. Bring family and friends to the facility to meet the residents
C. Return charts to their proper place after use
D. Post updates about favorite residents on her Facebook page to avoid being overheard
Correct answer:
The correct answer is C: Return charts to their proper place after use. This is the best way for a nursing assistant to keep residents' health information confidential because it ensures that sensitive information is securely stored and not left out in the open where unauthorized individuals may access it. By returning charts to their proper place, the nursing assistant maintains the confidentiality and privacy of residents' health information.
Choices A, B, and D are incorrect:
A: Discussing a resident's information away from the facility does not guarantee confidentiality as the information can still be overheard by others outside the facility.
B: Bringing family and friends to the facility can compromise residents' privacy as they may inadvertently overhear confidential information.
D: Posting updates about residents on social media violates their privacy and confidentiality, as this information can be accessed by a wider audience, including individuals who should not have access to it.
Which method of intrapartum fetal monitoring is the most appropriate when a woman has a history of hypertension during pregnancy?
A. Continuous auscultation with a fetoscope
B. Continuous electronic fetal monitoring
C. Intermittent assessment with a Doppler transducer
D. Intermittent electronic fetal monitoring for 15 minutes each hour
Correct answer:
The correct answer is B: Continuous electronic fetal monitoring. This method is most appropriate for a woman with a history of hypertension during pregnancy because it allows continuous monitoring of fetal heart rate patterns and uterine contractions, providing real-time data to detect any signs of fetal distress promptly. Continuous monitoring is crucial in high-risk pregnancies to ensure timely intervention if any issues arise.
A: Continuous auscultation with a fetoscope is not ideal for a woman with a history of hypertension as it does not provide continuous monitoring and may miss subtle changes in fetal well-being.
C: Intermittent assessment with a Doppler transducer does not offer continuous monitoring, which is essential in high-risk pregnancies like hypertension.
D: Intermittent electronic fetal monitoring for 15 minutes each hour is not as effective as continuous monitoring in detecting changes in fetal well-being promptly, which is crucial in cases of hypertension during pregnancy.
A patient presents to the ED complaining of a sudden onset of incapacitating vertigo, with nausea and vomiting and tinnitus. The patient mentions to the nurse that she suddenly cannot hear very well. What would the nurse suspect the patients diagnosis will be?
A. Ossiculitis
B. Mnires disease
C. Ototoxicity
D. Labyrinthitis
Correct answer:
The correct answer is D: Labyrinthitis. This condition presents with sudden onset vertigo, nausea, vomiting, tinnitus, and hearing loss, which are all symptoms described by the patient. Labyrinthitis is commonly caused by a viral infection affecting the inner ear, leading to inflammation of the labyrinth. This inflammation disrupts the balance and hearing functions of the inner ear, resulting in the symptoms mentioned.
A: Ossiculitis involves inflammation of the middle ear bones, typically causing conductive hearing loss, not the sudden onset of vertigo and other symptoms described.
B: Mnire's disease is characterized by recurrent episodes of vertigo, tinnitus, and hearing loss, but it typically does not present with sudden onset incapacitating vertigo.
C: Ototoxicity is caused by exposure to certain medications or chemicals that damage the inner ear structures, leading to hearing loss. While hearing loss is a symptom, the sudden onset of vertigo is not typically associated with ototoxicity.
A 27-year-old female patient is diagnosed with invasive cervical cancer and is told she needs to have a hysterectomy. One of the nursing diagnoses for this patient is disturbed body image related to perception of femininity. What intervention would be most appropriate for this patient?
A. Reassure the patient that she will still be able to have children.
B. Reassure the patient that she does not have to have sex to be feminine.
C. Reassure the patient that you know how she is feeling and that you feel her anxiety and pain.
D. Reassure the patient that she will still be able to have intercourse with sexual satisfaction and orgasm.
Correct answer:
The correct answer is B: Reassure the patient that she does not have to have sex to be feminine.
Rationale:
1. Acknowledges patient's feelings: By reassuring the patient that she does not have to have sex to be feminine, the nurse validates the patient's emotions and concerns.
2. Addresses societal norms: This intervention challenges societal stereotypes that equate femininity solely with reproductive capabilities.
3. Promotes self-acceptance: Encouraging the patient to embrace her femininity beyond physical aspects fosters self-acceptance and self-worth.
4. Supports holistic care: Recognizing the multifaceted nature of femininity shows a holistic approach to addressing the patient's body image issues.
Summary:
A, C, and D are incorrect as they do not directly address the patient's specific concerns about her body image and femininity. Choice B is the most appropriate intervention as it validates the patient's feelings and challenges societal norms, promoting self-acceptance and holistic care
RN exams clinical judgment practice questions, set 23 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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